Date with your dog: seize those summery days

Charlie takes a dip.

Summer is over, although the summer weather is hanging around and its a good opportunity to spend time doing some of those summery things with your dog that you know that at least one of you won't be keen to do in winter. Rae Anne sent these awesome photos of Jessie and Charlie doing what they love to do most.

Jessie strikes a pose in the water. 

This weekend we're hoping to explore the concept of "monotasking" just a bit further. We just have so many tasks to choose from!!! Since we've been posting a lot on the topic of burnout in the vet profession, SAT reader Ljudmila sent this fantastic link to a post about stress management for busy people.

Charlie dries off. (Note those stunning eyelashes)

Of course if you're NOT sure what to do with yourself this weekend, or do want to turn your thoughts to matters vetty, there are plenty of options.

The Australian Veterinary Association is surveying veterinarians about pet insurance. If you have feedback about pet insurance - good or bad - now is the time to make your voice heard. Click here to complete the brief survey. 

While you're in survey-mode, there is an equally important survey on the use of antimicrobials. Antimicrobial resistance is on the AVA's agenda and they're keen to use the data to create better prescribing resources. Click here to complete the survey.

Jessie splashes around.

The Centre for Veterinary Education has just announced that members will have FREE access to all of their webinars this year. Cat vet Kim Kendall kicks off with a talk on early desexing and behaviour issues in kittens on March 27. You can view the full program over here.

Happiness is...

The Animal Referral Hospital is hosting evening vet CE talks on the link between pain and behaviour (Dr Kersti Seksel, Behaviour specialist) and difficult-to-localise shoulder lameness (Dr Sarah Goldsmid, small animal surgery) on Tuesday April 8 (Campbelltown) and Thursday April 10 (Homebush). Contact ARH to sign up.

Ringworm (aka dermatophytosis)

Dr Patrizia Danesi (left) teaches a group of Italian veterinary students about dermatophytes with the aid of some plush toys. 

Ringworm gives everyone the heebie-jeebies, and I blame the name. Firstly, its not a worm, which goes some way to removing the freak-out factor - its fungal. Lots of different fungal species cause ringworm or dermatophytosis. And secondly, it can be staggeringly beautiful (see below).

M. canis (courtesy of the wonderful Dr Danesi).

The problem with dermatophytes is that they are zoonotic (i.e. infections can be transmitted from animal to human, and vice versa). In most cases clinical signs are mild.

Dermatophytes are fungi that are adapted to eat keratinous debris on the stratum corneum, hair shaft or claw (nails if you are a human). Microsporum spp and Trichophyton spp account for most animal disease, and despite its name, M. canis is best adapted to the cat. Cats are more susceptible to ringworm than dogs, which explains why most patients I've seen with ringworm are cats. Long-haired cats are at increased risk.

Younger animals are more commonly affected than older pets, most likely due to lack of specific immunity or poor development of innate immune mechanisms like sebaceous lipids in the epidermis.

Transmission is via contact with other affected animals, contamination of the environment with spores, or fomite transmission.

Clinical signs include hair loss or alopaecia around the face and ear tips especially, erythema, scale and crusting, itchiness or pruritis, sometimes a sheen to the lesion and rarely there is a nodular form which causes huge, pussy, inflammatory skin lesions to appear.

Diagnosis is challenging as it takes time...the fungus has to be cultured. You can occasionally see fungal spores on direct microscopic examination of hair plucks in liquid parraffin but a negative result doesn't rule out ringworm (i.e. the test has a low negative predictive value). Woods lamps are notoriously insensitive, detecting only M. canis and only in around 50 per cent of actual cases. Infection can also be confirmed by biopsy.

A ringworm lesion in a cat.

The lesions are often self limiting and can spontaneously regress, but we usually need to treat affected animals due to the risk of the infection spreading to other animals or humans. In animals, usually we use a combination of systemic medication (itraconazole, griseofulvin, ketoconazole) usually for 2-4 weeks following resolution of clinical signs, and topical methods (miconazole/chlorhexidine, enilconazole [in dogs] etc.) Clipping hair is recommonded by some textbooks but only a fool would do this in a vet hospital - think of the contamination!

Ringworm lesion on a vet nurse.

Humans seem to respond really well to topical treatment, maybe because we are less hairy? 

But back to animal patients - systemic antifungals aren't the most benign drugs and have side effects include vomiting, inappetance and hepatotoxicity. Some of the patients I have diagnosed have been far too young for systemic antifungals, so topical treatment and environmental decontamination are ideal.

For an excellent online resource on ringworm diagnosis and management, click here. The key is to be proactive and minimise cases by practising good husbandry. 

Reference

Bond R., (2010) Superficial veterinary mycoses Clinics in Dermatology 28: 226-236 

Do we breed companion animals ethically?

A Frenchie pops into the clinic for a visit.

Do we breed companion animals ethically? On Monday March 24, the Faculty of Veterinary Science is hosting its 4^th Robert Dixon Memorial Symposium from 3.30-5pm. Registration is free but you do need to RSVP.

The question will be approached by a panel of experts including Dr Linda Beer (vet and dog breeder), Dr Andrew Cornwell (NSW MP, Chair of the NSW Companion Animal Taskforce), Ms Maryann Dalton (Pet Industry Association of Australia executive officer), Dr Karen Hedberg (vet, breeder, judge and Chair of the Canine Health and Wellbeing Committee), Bidda Jones (RSPCA Australia Chief Scientist), Professor Richard Malik (small animal specialist) and Professor Claire Wade (geneticist).

You can sign up here.

Grooming is not something we should consider a treat for pampered pets: it is critical in maintaining the health and wellbeing of small animals. If you have worked in a shelter you may have encountered a case similar to this one, posted by the Quebec Society for the Protection of Animals. Knots and matts in fur are painful and restrict movement. (This story contains some upsetting images but has a really happy ending).

Here’s the best reason I’veever seen for taking up knitting: creating jumpers for penguins. Not for the sake of making them appear cute, although that is a happy side effect: they help prevent penguins affected by oil pollution from preening and swallowing the oil.

If you’re considering joining twitter, but think it’s just for people who want to troll celebrities or experience their 140 characters of fame on QandA, this brief slideshow might convince you otherwise.

How do veterinary employers tackle burnout?

A snap from AVA Sailing Day (much as I'd love to post a snap of colleagues in their budgie-smugglers, I'd also like to enjoy a long career in this profession...)

Last week the Australian Veterinary Association held its annual sailing day. Its a gathering of veterinarians (with a large number of practice owners), industry and AVA staff, and - unusually - its about having fun. Not continuing education. Not politics. Just hoofing around the harbour on a boat. 

Most of the time when I get together with colleagues we talk shop. It was a great reminder that the people we work with are actually fun-loving human beings. Wasn't it great, people were saying, to get together with people we work with and not have to talk about work?

I know that keen SAT readers have seen this before, but I could honestly look at this scene for hours. Store Beach National Park. A very good place to be.

Lately there has been a lot of discussion of work-related stressors that contribute to poor psychological health in vets. The recent loss of two colleagues has brought this home like a kick in the face.

Factors such as long working hours, after hours duties, relatively low remuneration, unexpected or undesirable clinical outcomes and managing client conflict are not sole concerns of the veterinary profession, but they are known contibutors to stress.

A recent survey of 860 veterinarians who graduated in the Netherlands from 1999 to 2009 found important gender differences. Around 73 per cent of respondents were female, reflecting the increased proportion of women in the profession.

The good news for new graduates is that, as has been found in other studies, exhaustion DECREASED over the years. Probably one learns to cope better with experience and tasks that were once overwhelmingly stressful become routine. 

BUT, male vets were less exhausted and more engaged in their jobs than females. 

While one in seven vets experienced burnout in the first ten years after graduation, around one in five females meet the criteria for burnout in their first five years after graduation. 

Compared with male colleagues, female vets experienced greater job demands and had moderately lower job and personal resources to cope with these. Other studies have found that female vets report greater emotional distress in relation to treatment failure or carrying out euthanasia than male vets.

But there are plenty of things employers can do to improve the situation. Giving employees some more control over the way their duties are carried out (for example the order in which these are performed), giving latitude around clinical decision making, providing support and opportunities for professional continuing education and skills development are all helpful in preventing exhaustion.

Meaningful continuing education, with the opportunity to use that new knowledge and skillset, improves engagement. But a positive working environment is critical.

At the university level we also need to focus on developing student's personal resources, particularly as the author's suggest proactive behaviour and self-efficacy. 

As a practitioner I think these studies are so important, but one key deficiency is the failure to date (if anyone knows of any studies contradicting this, please let me know) to assess the impact of stressors on the whole veterinary team. Nurses, kennel and admin staff are all part of the team and the interaction between team members is also important. 

One of the colleagues we lost was an exceptional nurse/wildlife carer. Not a vet. He didn't graduate, was never mentored, didn't have formal continuing education. 

I've never worked in a job before where the outcome relied so much on the experience of all team members as it does in this profession. Understanding the dynamic between vets and nurses, and clients and nurses, as well as stressors experienced by nurses and support staff, is so important in keeping this profession healthy.

References

Mastenbroek NJJM, Jaarsma ADC, Demerouti E, Muijtjens AMM, Scherpbier AJJA & van Beukelen (2014) Burnout and engagement, and its predictors in young veterinary professionals: the influence of gender. Veterinary Record February 8:doi 10.1136/vr101762.

Meehan MP (2014) Psychological wellbeing of veterinary professionals. Veterinary Record February 8:142-143.

Three things I learned: anaemia in the cancer patient

Randy loves his new Timothy Hay house. Its nothing to do with anaemia in oncology patients, but its a little dose of happiness at the beginning of the week.

Aloha Monday! Last week SydneyUniversity oncologist Peter Bennett presented a fantastic overview on anaemia in the cancer patient. (For those who don't know, we're currently enrolled in the Centre for Veterinary Education Distance Ed oncology program, taught by Dr Bennett. I highly recommend it).

[If you don't feel like reading about anaemia in oncology patients, here's another pic of Randy].

A timothy-hay house acts simaltaneously as a shelter and a snack.

Cushing enjoys the house too.

Anaemia is a problem in cancer patients for a range of reasons. It is associated with a poorer overall prognosis, as well as poor wound healing, decreased appetite (especially in cats), increased anaesthetic and surgical risk and increased risk of toxicity associated with chemotherapy or radiation. The aim is to avoid it, or recognise and treat anaemia where necessary.

The most important thing I learned (well, I knew it but it was reinforced) is that cancer patients develop anaemia for a variety of reasons which can be categorised under:

1. Decreased production of red blood cells (this is the most common form)
2. Increased loss
3. Increased destruction

Decreased production

Anaemia of chronic disease is the most common form of decreased production in the cancer patient and is usually mild. It usually causes a non-regenerative, normocytic, normochromic anaemia.

Myelophthisis (bone marrow suppression due to marrow infiltration by tumour cells with local production of myelosuppressive cytokines) is more common in dogs than cats, and tends to be seen with lymphoid tumours and leukaemias. This can vary from mild to severe. Red blood cells are often the last cell line to decrease, with thrombocytopaenia often occurring in the early stages. It causes a non-regenerative, normocytic, normochromic anaemia, as does chemotherapy associated anaemia.

Iron deficiency anaemia is uncommon but usually secondary to gastrointestinal or external blood loss that is ongoing and severe. It causes a non-regenerative, microcytic, hypochromic anaemia.

Increased loss

This is most common with vascular tumours such as Haemangiosarcoma and haemangiomas. Any splenic tumour has a very high risk of bleeding and most have at least one haematoma associated with them. Hepatic tumours can also bleed. Clinical signs can be cyclical as the animal has an internal bleed then autotransfuses over 3-4 days, hence they can appear weak and lethargic and bounce back. Autotransfusion itself can cause red blood cell changes, e.g. schistocytes.

Initially animals with anaemia secondary to vascular tumours will have a non-regenerative, normocytic, normochromic anaemia, but over time this can become regenerative, with macrocytosis, polychromasia an reticulocytosis (though autotransfusion can blunt the regenerative response).

Blood loss commonly occurs in the GIT, with epithelial tumours bleeding the most. Melena is not always seen or recognised by owners. Around 5-10 per cent of dogs with mast cell tumours will have gastrointestinal ulcers, but significant bleeding will only occur in a fraction of these. Other potential causes of GI ulceration include gastrinomas, renal failure and liver failure (lymphoma a common culprit). Animals with nasal tumours may swallow blood, so epistaxis isn’t always present. It can be tricky in some cases to differentiate nasal from gastrointestinal bleeding.

Usually the signs of the tumour will predominate over signs of anaemia – for example, with GIT tumours, the predominant signs will be vomiting, diarrhoea and weight loss. These animals may have a moderate to severe hypoproteinaemia.

Primary and secondary coagulopathies can occur. Immune mediated thrombocytopaenia is often associated with lymphoma. Dogs with haemangiosarcoma are at increased risk of disseminated intravascular coagulation (DIC) – strangely enough DIC (or IC at any rate) can be localised to the spleen. Mast cell tumours produce anticoagulant factors such as heparin.

The anaemia is usually regenerative.

Increased destruction

The main causes in cancer patients are immune-mediated haemolytic anaemia (IMHA), microangiopathic haemolytic anaemia and erythrophagocytosis.

IMHA is a common cause of severe anaemia in cancer patients and is most often associated with lymphoid malignancies. The aetiology is not fully understood but it might be due to altered immune function or the presence of surface antigens on tumour cells that are shared by red blood cells. It usually causes regenerative anaemia. Quite often in these cases the animal will present for signs of anaemia and the cancer is discovered during work up, rather than the other way around.

Microangiopathic haemolytic anaemia is most often seen with vascular tumours such as haemangiosarcomas, but it can be seen with lymphoma. Red cells cop a beating when they pass through vascular channels containing fibrin strands, and these damaged cells are removed by the spleen. Dr Bennett said there is probably also an immune-mediated component. There is a regenerative anaemia, often with signs of erythrocyte damage e.g. schistocytes.

Erythrophagocytosis is seen with the aggressive form of histiocytic sarcoma. Bernese Mountain Dogs are over-represented here. As the name suggests, the cancer cells actually phagocytose (eat) red blood cells. It causes a severe regenerative anaemia.

What do you do about it?

The trick can be working out which kind of anaemia the patient has. Small tumours can be associated with severe anaemia and large tumours can be associated with mild anaemia – or vice versa. The presentation of the animal depends on the tumour type, stage and grade.

Obviously the first step is to identify anaemia (low haematocrit and haemoglobin), but also find out in the history whether onset is acute or chronic. Have there been signs of lethargy, pallor, weakness, exercise intolerance, reduced appetite, dyspnoea? For how long? Have there been episodes of external blood loss?

Signs to look for on physical exam include obvious signs of external haemorrhage, a fluid wave, muffled ventral lung/heart sounds, pallor or signs of coagulopathy. Mast cell tumours may be associated with gastric ulceration, so cutaneous tumours can be an important clue in the work up of anaemia.

A rectal exam should be performed to check the faeces and rectal mucosa for blood. I knew that recent (ie within 4 days) ingestion of meat could interfere with occult faecal blood test results – but ingestion of green vegies in the same time period can also give a false result.

A CBC/MBA and UA should be performed, but its always important to perform a blood smear for morphological evaluation.

Treatment of anaemia depends on the severity and the underlying cause. Ideally, we diagnose and eliminate the underlying cause (for example, remove the bleeding tumour). Other treatment may include blood or platelet rich plasma transfusion, oxygen, rest, gastroprotectants, vitamin K, withdrawal of certain drugs from the treatment regime or immunosuppression – depending on the particular case.

Withdrawal of chemotherapy drugs should be carefully considered as it brings the risk of disease relapse. Use of an alternate agent can be considered although it is likely to have similar effects, or EPO can be given (though Dr Bennett doesn’t feel this really helps in most cases).